Integrated Impact of Post-TAVR Cardiac Damage and Pacemaker Implantation on Long-Term Outcomes

Background/Objectives: Post-procedural permanent pacemaker implantation (PPMI) and cardiac damage are individually associated with adverse outcomes following transcatheter aortic valve replacement (TAVR). However, their joint impact has not been systematically evaluated. Methods: Individuals who underwent TAVR procedures between 2013 and 2024 were retrospectively enrolled and classified into four groups based on their PPMI and cardiac damage status. Univariate and multivariable Cox regression were used to analyze the association of these factors with long-term outcomes, while receiver operating characteristic (ROC) curves, decision curve analysis (DCA), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to further assess their predictive performance. Results: A total of 1274 patients met the inclusion criteria. Compared to non-PPMI patients with early cardiac damage stage, those with PPMI and advanced stage had higher all-cause mortality (HR: 2.98; 95% CI: 1.60-5.56; p value < 0.001) and more cardiac deaths (HR: 3.85; 95% CI: 1.36-11.10; p = 0.012). Multivariable analysis confirmed PPMI and cardiac damage stage as independent prognostic factors. Notably, the predictive model incorporating both variables achieved the best performance (AUC = 0.703) with significant NRI and favorable DCA results, suggesting incremental value for identifying high-risk patients and acceptable clinical utility. Conclusions: The current study is among the first to explore whether post-procedural cardiac damage may identify a subgroup in whom PPMI carries a particularly adverse long-term prognosis, highlighting the need for integrated risk assessment for post-TAVR lifelong management.